Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged incident of abuse within the required two-hour timeframe to the California Department of Public Health (CDPH) as mandated by federal regulations. The incident involved a resident with Alzheimer's disease and moderate cognitive impairment who was admitted to the facility and reportedly hit another resident in the face. The event was documented in the resident's change of condition record, and the care plan indicated that notifications to CDPH, law enforcement, and the Ombudsman were made, but the actual report to CDPH was not sent to the correct number. The resident who was struck had a history of anxiety and personality disorder, with intact cognitive abilities according to their most recent assessment. During an interview, this resident reported feeling traumatized by the incident. The Social Services Director confirmed that the fax containing the abuse allegation was sent to the wrong number, which could delay the investigation process. The Director of Nursing also acknowledged that the incident was not reported to the correct CDPH number, which could have impacted the timely investigation of the abuse allegation. A review of the facility's policy and procedure on abuse reporting confirmed that allegations of abuse are to be reported to the state licensing and certification agency within two hours. However, the failure to report the incident to the correct authority within the required timeframe constituted noncompliance with federal and facility policy requirements.
Plan Of Correction
F609: Reporting of Alleged Violations CORRECTIVE ACTIONS The reported allegation of abuse involving resident 51 and resident 10 was documented on 1/22/25. On 3/7/25, upon identification of the incident being sent to the wrong fax number of CDPH for reporting allegations, the Administrator, in collaboration with SSD, updated the contact numbers of CDPH visible by the main fax machine. Resident 10 was reassessed on 1/22/25, with no injuries or signs of emotional distress observed related to the alleged incident. On 3/25/25, the Director of Staff Development conducted an in-service training for facility staff on the facility's policies and procedures for abuse reporting, including the correct contact number posted on the facility's main fax machine. The Director of Nursing (DON) also provided in-service training on 3/25/25 for licensed nurses, focusing on the facility's abuse reporting procedures and proper use of the SOC-341 form and sending it to the correct contact number. OTHER RESIDENTS AFFECTED IDENTIFICATION All active residents, including newly admitted residents, may be impacted by this deficiency. The IDT conducted a Resident QA survey/interview with 7 alert and oriented residents from 3/21/25 to 3/27/25. All 7 residents reported that they had never experienced any inappropriate contact or interaction that made them feel unsafe. No negative effects or adverse outcomes have been reported or observed as a result of this deficiency. MEASURES AND SYSTEMIC CHANGES All reported allegations of abuse will be thoroughly investigated and discussed during the stand-up meeting with the IDT. Department Heads will continue conducting the Resident QA interview survey for residents who can participate. For those unable to participate, the responsible party or family will be contacted during room rounds once per week for three months to gather feedback on the interview questions. The results of the QA satisfaction interviews will be reported to the Administrator for timely follow-up and reporting. The Director of Staff Development conducted follow-up in-service for facility staff from 3/21/25 to 3/25/25 on abuse prohibition and management, with additional training provided quarterly thereafter. As part of the new employee orientation program and the annual skills competency evaluation, the DON/DSD will review the facility's Abuse Prevention and Prohibition Program. This includes policies and procedures on timely reporting of abuse to the Abuse Coordinator, DON, or Supervisor, ensuring resident protection, implementing immediate interventions, and initiating investigations to safeguard resident safety. MONITORING PERFORMANCE The administrator shall ensure the ongoing and sustained execution of the above process. Additionally, the administrator shall report any identified trends from the resident/family QA satisfaction interviews to the QAA committee monthly for three months or until compliance is achieved, for further review and additional recommendations.